The effect of anterior palatine blocks on bleeding in hereditary hemorrhagic telangiectasia nasal surgery.

OBJECTIVES/HYPOTHESIS: When combined with local sphenopalatine (SP) injection and moderate hypotension, transoral or transcutaneous local injection of the anterior palatine (AP) vessels reduces intraoperative bleeding in hereditary hemorrhagic telangiectasia (HHT) patients undergoing nasal surgery. STUDY DESIGN: Retrospective chart review of 55 consecutive HHT patients undergoing a bevacizumab injection for recalcitrant epistaxis. Nineteen patients received local injections to only the SP vasculature, and 36 patients received AP and SP injections. METHODS: Main outcome variable was estimated blood loss during nasal surgery. Independent variables included sex, age, epistaxis severity score, surgical techniques (including laser), and blood pressure parameters (baseline, preinduction, and postintubation). RESULTS: The mean blood loss in HHT patients receiving SP injections alone was 111 mL, whereas it was 22 mL for those receiving both AP + SP injections. This difference between groups approached statistical significance (P = .075). Blood pressure parameters were similar in both groups with no appreciable difference between intraoperative systolic and mean arterial blood pressure. CONCLUSIONS: The addition of either sublabial or transcutaneous AP injection to the standard SP block markedly reduces blood loss in HHT epistaxis nasal surgery.

Osteolipoma presenting as a submandibular mass: a rare presentation.

Osteolipomas are rare tumors, particularly in the head and neck region, in contrast to lipomas which are the most common benign neoplasms in this location. Osseous changes are benign and mainly occur in long-standing lipomas. Despite its rarity, this neoplasm has a characteristic histopathologic appearance with lamellar bony spicules within the mature adipose tissue. Of the 19 cases previously reported in the oropharyngeal area, only two were located in the submandibular region. We report the third case of submandibular osteolipoma, presenting as an asymptomatic mass in a middle-aged man. Our review of head and neck osteolipomas would be of particular interest to pathologists and head and neck surgeons, in order to avoid inappropriate treatment of an otherwise benign lesion.

Treatment of hereditary hemorrhagic telangiectasia with submucosal and topical bevacizumab therapy.

OBJECTIVE/HYPOTHESIS: Bevacizumab delivered as a submucosal and topical intranasal therapy effectively controls hereditary hemorrhagic telangiectasia (HHT)-associated epistaxis. STUDY DESIGN: Prospective institutional review board-approved study. METHODS: Between December 2009 and December 2010, 19 patients with HHT-associated epistaxis were treated with 100 mg of intranasal submucosal bevacizumab. Following treatment, patients were contacted monthly to report their epistaxis severity score (ESS) for 9 or more months after their initial treatment. If a patient had a significant increase in their ESS, they were offered treatment with 100 mg of topical bevacizumab, administered via a metered dose atomizer. All treatments were recorded. RESULTS: All 19 patients had a postinjection ESS documented through 9 months, whereas 17 patients had completed ESS data between months 10 and 12. Six of the 19 patients received eight additional 100 mg of topical bevacizumab treatments because they had an increase in their ESS. Results demonstrated a mean preinjection ESS of 8.12, with an ESS nadir of 2.00 reached at 2 months following submucosal injection (P < 0.0001). Over the following 12 months, the mean ESS steadily increased back to a maximum of 3.6 reached at 11 months following injection (P < .0001). CONCLUSIONS: Intranasal submucosal bevacizumab effectively treats HHT-associated epistaxis for up to 12 months following treatment.

Efficacy of intranasal Bevacizumab (Avastin) treatment in patients with hereditary hemorrhagic telangiectasia-associated epistaxis.

OBJECTIVES/ HYPOTHESIS: Intranasal Bevacizumab is an effective therapy for epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN: Retrospective chart review. METHODS: In 32 successive patients presenting with recurrent HHT epistaxis 25-100 mg of Bevacizumab was applied intranasally either as a submucosal injection or as a topical spray between November 2008 and May 2010. In many of the injected patients, the Potassium Titanyl Phosphate (KTP) laser was used adjunctively for vessel photocoagulation. A phone interview was performed in July 2010 to assess for treatment efficacy. RESULTS: All 32 treated patients were contacted with pre- and posttreatment epistaxis severity scores (ESS) compared. Seventeen patients received topical Bevacizumab, 10 patients received a submucosal injection, and 5 patients received both. In addition, 12 patients were also treated with the KTP laser at the time of their submucosal injection. In the pretreatment period the average ESS was 7.0 (SD = 2.1), whereas in the posttreatment group the average ESS was 2.9 (SD = 1.7). This represents a significant improvement in epistaxis severity (P < .0001). CONCLUSIONS: In HHT patients intranasal Bevacizumab, applied as a topical spray or a submucosal injection, significantly improves epistaxis as measured by the Epistaxis Severity Score.

Safety of intranasal Bevacizumab (Avastin) treatment in patients with hereditary hemorrhagic telangiectasia-associated epistaxis.

OBJECTIVES/HYPOTHESIS: Assess for complications of intranasal Bevacizumab application in patients with hereditary hemorrhagic telangiectasia (HHT)-associated epistaxis. STUDY DESIGN: Retrospective chart review. METHODS: In 58 patients presenting with recurrent HHT epistaxis, Bevacizumab was applied intranasally either as a submucosal injection or as a topical spray between October 2006 and June 2010. In many of the injected patients, the potassium titanyl phosphate (KTP) laser was used adjunctively for vessel photocoagulation. A phone interview was performed in July 2010 to assess for treatment complications. RESULTS: Of the 58 treated patients 52 were contacted. Patient surveys were performed 1.5 to 46 months following their initial Bevacizumab treatment. Within the treatment population, five patients had sustained a septal perforation. Notably, these patients were treated early in the study period at which time the cartilaginous septum was often both injected and lasered. Subsequently, the treatment protocol was changed and the cartilaginous septum was neither lasered nor injected. After these changes were made no additional septal perforations were identified. No other adverse events were associated with intranasal Bevacizumab treatment. CONCLUSIONS: Bevacizumab applied as either a submucosal injection or as a topical nasal spray, with or without application of the KTP laser, is a safe treatment regimen. Still, when Bevacizumab injections are performed, the cartilaginous nasal septum should be avoided as patients may develop septal perforations.

The Bradford Hill criteria and zinc-induced anosmia: a causality analysis.

OBJECTIVE: To apply the Bradford Hill criteria, which are widely used to establish causality between an environmental agent and disease, to evaluate the relationship between over-the-counter intranasal zinc gluconate therapy and anosmia. DESIGN: Patient and literature review applying the Bradford Hill criteria on causation. SETTING: University of California, San Diego, Nasal Dysfunction Clinic. PATIENTS: The study included 25 patients who presented to the University of California, San Diego, Nasal Dysfunction Clinic complaining of acute-onset anosmia after intranasal application of homeopathic zinc gluconate gel. MAIN OUTCOME MEASURES: Each of the 9 Bradford Hill criteria--strength of association, consistency, specificity, temporality, biological gradient (dose-response), biological plausibility, biological coherence, experimental evidence, and analogy--was applied to intranasal zinc gluconate therapy and olfactory dysfunction using published, peer-reviewed medical literature and reported clinical experiences. RESULTS: Clinical, biological, and experimental data support the Bradford Hill criteria to demonstrate that intranasal zinc gluconate therapy causes hyposmia and anosmia. CONCLUSIONS: The Bradford Hill criteria represent an important tool for scientifically determining cause between environmental exposure and disease. Increased Food and Drug Administration oversight of homeopathic medications is needed to monitor the safety of these popular remedies.

Hereditary hemorrhagic telangiectasia/avastin.

This is the first scientific report of hereditary hemorrhagic telangiectasia (HHT) epistaxis treatment by intranasal spraying of the vascular endothelial growth factor (VEGF) inhibitor bevacizumab (Avastin). Epistaxis in patients with HHT is a morbid, mortal condition that is difficult and unpleasant to manage. Nasal telangiectasia growth is modulated by VEGF, which is elevated in HHT patients. Bevacizumab is a VEGF inhibitor that diminishes epistaxis when administered intravenously or injected locally, or as reported here when sprayed topically onto the nasal mucosa.

Toxin-induced chemosensory dysfunction: a case series and review.

BACKGROUND: Toxic chemical exposures are estimated to account for 1-5% of all olfactory disorders. Both olfactory neurons and taste buds are in direct contact with environmental agents because of their relatively unprotected anatomic locations, thereby making them susceptible to damage from acute and chronic toxic exposures. The aim of this study was to illustrate different aspects of the diagnostic and therapeutic approach to this disorder using a series of case reports and review of the literature. METHODS: Cases were selected for inclusion based on a retrospective chart review of patients who presented to a university-based nasal dysfunction clinic with toxin-induced olfactory or gustatory dysfunction between January 1985 and December 2008. Workup included complete history, otolaryngologic examination, psychophysical testing, and imaging. RESULTS: Patient ages ranged from 31 to 67 years (mean, 49.3 years). Etiology of chemosensory impairment included exposure to ammonia, isodecanes, hairdressing chemicals, chemotherapy, gasoline, and intranasal zinc. Five of the seven patients (71%) presented with olfactory dysfunction alone, one patient (14%) presented with dysgeusia alone, and one patient (14%) presented with both smell and taste loss. Only one patient (14%) reported parosmias. Tests of olfaction revealed normosmia in one patient (14%), mild-to-moderate hyposmia in one patient (14%), and severe hyposmia to anosmia in five patients (72%). Both patients who reported taste disorders had hypogeusia on testing. CONCLUSION: This case series illustrates the wide spectrum of this disorder and provides a framework for the workup and treatment of these patients.

Relative hypotension and image guidance: tools for training in sinus surgery.

OBJECTIVES: To quantify the safety and efficiency of Postgraduate-Year II head-and-neck-surgery residents who perform endoscopic sinus surgery, to observe any changes that accompanied accrued experience, and to measure and correlate blood loss and temporal efficiency with anesthesia-induced relative hypotension. DESIGN: Retrospective study. SETTING: University of California, San Diego, Medical Center. PATIENTS: One hundred two patients with chronic rhinosinusitis operated on between July 1, 2005, and June 30, 2006, by 3 Postgraduate-Year II head-and-neck-surgery residents. INTERVENTION: Endoscopic sinus surgery. MAIN OUTCOME MEASURES: Operative times, blood loss, case complexity, and anesthetic components were recorded and analyzed. RESULTS: One hundred two patients with chronic rhinosinusitis with and without polyposis received operative management. Mean operative time, with the inclusion of injection (10 minutes) and image guidance setup (5 minutes), was 77 minutes. Estimated blood loss averaged 42 mL for patients with chronic rhinosinusitis and 58 mL for patients with chronic rhinosinusitis and nasal polyps. The mean intraoperative blood pressure was 101/65 mm Hg. No major complications occurred. CONCLUSIONS: Endoscopic sinus surgery may be safely performed by Postgraduate-Year II head-and-neck-surgery residents by means of hypotensive anesthesia techniques and image guidance. Outcome analysis demonstrates minimal blood loss, efficient operative times, and no significant complications.

Regional variations in chronic rhinosinusitis, 2003-2006.

OBJECTIVES: 1. Characterize patient visits for chronic rhinosinusitis on the basis of age, gender, race, diagnostic services, and medication use. 2. Evaluate regional differences in patient visits for chronic rhinosinusitis. STUDY DESIGN: Analysis of cross-sectional survey data from two national databases of ambulatory medical encounters. SETTING: Not applicable. SUBJECTS AND METHODS: Four years (2003-2006) of data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed. Visits involving chronic rhinosinusitis were identified by using reported diagnostic codes from the International Classification of Diseases, Ninth Revision. They were weighted to provide national estimates of care. Data were analyzed with the Pearson chi(2) test using the SPSS 16.2 Complex Samples Module, taking into account the complex survey design and multiple time periods. RESULTS: A total of 4617 patient visits for chronic rhinosinusitis were identified, accounting for 1.95 percent of all visits. With the application of weights to this sample, these visits represent 91.2 million national visits. A significantly higher proportion of visits in the South involved African Americans (Pearson chi(2) = 69.5, F = 6.7, df = 2.8, 2118, P < 0.01). Significantly fewer diagnostic services were provided or ordered in the Northeast (Pearson chi(2) = 64.8, F = 4.0, df = 4.3, 3247, P < 0.01). Providers in the Northeast were also significantly less likely to order or renew more than three medications at the visit (Pearson chi(2) = 54.0, F = 3.1, df = 2.6, 1930, P < 0.05). No regional differences were seen for age, gender, or setting type. CONCLUSION: Significant regional variations exist for chronic rhinosinusitis in patient demographics, diagnosis, and management. Continuing research is needed to refine physician awareness, evaluation, and treatment of this disorder.

The effect of bevacizumab (Avastin) treatment on epistaxis in hereditary hemorrhagic telangiectasia.

OBJECTIVES/HYPOTHESIS: Determine the effectiveness of treating epistaxis in hereditary hemorrhagic telangiectasia (HHT) with potassium titanyl phosphate (KTP) laser cautery combined with submucosal injection of 100 mg of bevacizumab. STUDY DESIGN: Retrospective pilot study. METHODS: Bevacizumab was injected throughout the nasal cavity following KTP laser treatment in 10 patients (bevacizumab/KTP group) and compared to nine patients previously treated with KTP laser alone (KTP group). Epistaxis frequency and severity, blood transfusion requirement, intravenous iron supplementation, emergency department visit frequency, and quality of life within 1 month and 1 year pre- and postsurgery were analyzed. Benefit was defined as less than three nosebleeds per week, with less than 10 minutes to stop each nosebleed, and no blood transfusions. The pre- and postsurgery data were analyzed within and between the two groups. RESULTS: The groups were comparable in age and gender. Significant benefit was found in frequency of epistaxis (P < .05), number of blood transfusions (P = .04), disability (P = .01), and effect on social life (P = .03) 1 month pre- and postsurgery in the bevacizumab/KTP group. Eighty percent of bevacizumab/KTP group patients reported benefit in comparison to 56% in the KTP group. CONCLUSIONS: KTP laser combined with bevacizumab in HHT epistaxis is superior to KTP laser treatment alone. It significantly decreases frequency and severity of nosebleeds and blood transfusion requirements, and significantly improves work ability and quality of life.

Sleep medicine for surgeons.

Sleep medicine is an important component of current head and neck surgery practices. Furthermore, obstructive sleep apnea is an anatomic disease of the upper respiratory tract, a region of anatomy best known to head and neck surgeons. If head and neck surgeons choose to participate in the surgical treatment of sleep apnea, they must develop expertise in the evaluation and home sleep testing aspects of sleep apnea. Because positive airway pressure remains the front line treatment, they must also develop expertise in the prescription of positive airway pressure therapy.

Waist circumference and sleep disordered breathing.

OBJECTIVES/HYPOTHESIS: To explore how the different metrics of obesity, specifically body mass index (BMI), Mallampati, neck circumference, waist circumference, and waist-hip ratio, correlate with metrics of sleep disordered breathing (SDB), specifically the apnea/hypopnea index (AHI), and which is/are the most likely to predict and correlate with SDB. STUDY DESIGN AND METHODS: Four hundred fourteen patients presenting to the University of California San Diego Head and Neck Surgery Clinic for SDB had a sleep evaluation including a history and physical examination assessing the markers of obesity and a sleep test. Data comparing AHI with BMI, neck circumference, waist circumference, waist-hip ratio, and Mallampati were analyzed by means, standard deviations, and Pearson's correlations. RESULTS: The mean AHI for males was 34, and the mean AHI for females was 24. The mean age was 48 for both sexes. The mean waist circumference for males was 104 cm (41 inches) and for females 99 cm (39 inches). In males and females, waist measurement was most strongly correlated with SDB (males: r = 0.366, P = .00; females: r = 0.445, P = .00). The mean neck circumference for males and females was 43 cm (17 inches) and 38 cm (15 inches) (males: r = 0.358, P = .00; females: r = 0.38, P = .00). The mean waist-hip ratio for males and females was 0.94 and 0.87 (males: r = 0.359, P = .00; females: r = 0.254, P = .03). The mean BMI for males and females was 31 kg/m2 (males: r = 0.325, P = .00; females: r = 0.40, P = .00), and the mean Mallampati for males and females was 2.84 and 2.92 (males: r = 0.176, P = .012; females: r = 0.149, P = .16). A linear regression demonstrated that waist and neck circumference were better correlates of SDB than BMI. CONCLUSION: Obesity correlates with SDB severity. Waist circumference is a better measure than BMI or neck circumference to predict SDB. Men and women are anthropometrically different. Even with an AHI of 5 or more, only half of SDB patients in this study were clinically obese. An abnormal waist circumference for men and women is 102 cm (40 inches) or more.

A two-dimensional model of anatomic relationships during laryngoscopy.

BACKGROUND: The view obtained during direct laryngoscopy is only seen by a single anesthesiologist. The inability of instructors to observe the view poses problems for teaching the technique. The anatomic interactions affecting laryngoscopy are largely internal, hampering efforts to understand why some patients are unexpectedly difficult to intubate. In response, we have constructed a full scale, adjustable, two-dimensional model showing the head and neck in the sagittal plane. In this article, we validate the mannequin and test how various conditions or changes in equipment affect the laryngoscopic view. METHODS: Model parameters were compared with literature values. Glottic exposure was evaluated over a range of jaw lengths and interincisor gaps for Macintosh 3, Miller 2, and Macintosh 4 blades. RESULTS: Thirty segmental airway distances and 10 angles were within 1 standard deviation from published values. Spine and jaw mobilities approximated normal range of motion. Glottic exposure decreased steeply for mouth openings below a threshold. A larger mouth opening was required to obtain a view when the mandible was short. None of the blades exposed the glottis when mouth opening was narrow, 2.4 cm. The Macintosh 4 blade was closest to success, within 7 mm of viewing the posterior cords. CONCLUSIONS: The model reflects an average 16-yr-old male patient in size, proportion, and mobility. It can be used to explicate how anatomic relationships affect laryngoscopy. An objective assessment is necessary to determine the model's utility for teaching and as a tool for researching the mechanisms responsible for laryngoscopic difficulty.

Home sleep testing in the diagnosis and treatment of sleep disordered breathing.

Sleep-disordered breathing is a growing public health concern and an integral part of head and neck surgery. Multichannel home sleep testing is a cost-effective, patient-friendly, scientifically valid technique of evaluating patients who present with symptoms of sleep-disordered breathing, typically snoring or daytime sleepiness. Home sleep tests can be dispensed from the physician's office. They have a 95% successful recording rate. Scoring can be autoscore or manual score. There are several protocols that can be followed based on diagnostic outcomes.

Use of a sprayed fibrin hemostatic sealant after laser therapy for hereditary hemorrhagic telangiectasia epistaxis.

BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a relatively common autosomal dominant condition. Epistaxis is a frequent manifestation, often occurring daily and requiring iron and blood transfusions. Surgery often is bloody and difficult. The aim of this study was to evaluate the effectiveness of a sprayed fibrin, hemostatic sealant in preventing postoperative epistaxis after laser treatment of nasal mucosa in HHT. Fibrin sealant was compared with nasal packing for likelihood of postoperative epistaxis and financial impact including material costs and hospitalization fees. METHODS: Retrospective review was performed of 64 individual laser treatments for epistaxis in HHT patients at the University of California, San Diego, Medical Center between 2002 and 2005. Nasal packing was used in 30 procedures and fibrin sealant was used in 34 procedures. RESULTS: Six of 30 (20%) procedures using postoperative nasal packing required admission with an average hospital expense of $5914. One of 34 patients (3%) in the fibrin sealant group required hospitalization (p = 0.04). CONCLUSION: Aerosolized fibrin sealant prevents postoperative epistaxis after nasal laser treatment in HHT patients. Compared with traditional nasal packing we found improved patient comfort and recovery with substantial cost savings.

Tissue preparation for MOHS' frozen sections: a comparison of three techniques.

Accurate, efficient frozen section analysis is important for tumor control. A few studies address the technical issues. More are needed, especially as new technologies become available. The objective of this study is to compare the efficiency of three techniques of flattening tissue for microscopically oriented histologic surgery (MOHS): conventional frozen sectioning, Cryocup, and CryoHist. Conventional chuck/heat sink-frozen section preparation were compared with Cryocup and CryoHist to determine the most efficient technique to examine 100% of the surgical margin of 4-cm diameter, full thickness, fresh autopsy cylinders of anterior abdominal skin, which were marked on their deep and peripheral margins. The specimens were frozen sectioned at 5 microm until all the marking dye was gone from the deep surface, and 95% of the perimeter epidermis could be seen. The conventional chuck required an average of 304 micrometers to clear the deep margin and four fifths did not contain 95% of the epidermal margin. The Cryocup required an average of 284 microm to examine the deep margin and 95% of the epidermal margin. The CryoHist required an average of 104 microm to examine the deep margin and 95% of the epidermal border. The new techniques improve the efficiency and presumably the accuracy of tumor margin analysis.

Searching the literature using medical subject headings versus text word with PubMed.

OBJECTIVE/HYPOTHESIS: This study was conducted to investigate the performance of two search strategies in the retrieval of information from the National Library of Medicine (NLM) on otolaryngology-head and neck surgery related conditions and diagnoses using PubMed. METHODS: Two search strategies-one based on the use of Medical Subject Headings (MeSH) and the second based on text word searching-were compared. RESULTS: The MeSH search provided a more efficient search than the text word search. CONCLUSIONS: Head and neck surgeons can most efficiently search the NLM using PubMed as a search engine by initiating the search with MeSH terms. Once a key article is identified, the searcher should use the "Related Articles" feature.